Forceps Delivery by Abhishek Jaguessar

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FORCEPS DELIVERY

An Overview

BY

ABHISHEK JAGUESSAR


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12 October 2002 Forceps Delivery - Prof.S.N.Panda 2

Introduction

In the last several decades, obstetrics, as a science hasundergone phenomenal development with a proper

understanding of the entire process of pregnancy & childbirth.

The present day labour management is basically influenced

by two factors:

The availability of various modalities of antepartum & postpartum

foetal monitoring that gives the obstetrician precise knowledge of

the foetal condition, which enables him not only to terminate the

pregnancy & labour but also document his decision.

The developments in the fields of anaesthesia, antibiotics, blood

transfusion, surgical aids & techniques have made a once dreaded

operation - "caesarean section ", very safe to-day.


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Introduction

In view of these developments, the expectations of all concerned -patient, relatives, attending doctors & authorities including legal system

has undergone a sea change so that a small mishap will be viewed

seriously.

In such a scenario, the practicing obstetrician of today is likely to havereservations about using instrumental labour management methods of

unpredictable course & outcome. Hence today instrumental deliveries

are becoming rarer and rarer. In the last two decades, not only very few

developments have taken place in this field, many of the instrumental

deliveries have become obsolete.

However in the present day concept of active management of labour ,

forceps still have their own place and should be considered in suitable

cases, particularly in developing countries like India.


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History

Earliest mention of instrumental delivery in Vedic era -"Ankush."

Albucasis described forceps with teeth on the inner surface fordead foetus.

WILLIAM CHAMBERLAIN Fled from France in 1569 & practiced forceps delivery as a family

secret in Southampton. This was kept as a family secret for over100yrs and four generations.

He had two sons. Peter I - had greater distinction & attended notable women in society. Was

summoned by R.C.P. & Jailed in 1612. He had no sons.

Peter II - who had several sons, died in 1626.


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History

Dr Peter III- the most prominent one studied inCambridge, Oxford, and Padua. Elected a fellow ofR.C.P. Died in 1683 in Woodham Mortimer Hall.It isbelieved that the family treasure was kept buried here,which was latter unearthed in 1813 by the thenoccupant Mrs.Kembell.

Hugh- had interest in politics, was forced to flee to

France, where in 1673 he sold the family secret toMauriceau. After few years he went to Holland & againsold the secret (only one blade) to Roser Roomhuysen.


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History

Hugh (son of Hugh)-who was highly educated and respected hadpatients from best families including Duke of Buckinghamallowed the family secret to leak.

The Chamberlain family used four pairs of forceps of different sizes withonly cephalic curve.

Levret (1747)-introduced the pelvic curve Smellie (1751)- reinforced pelvic curve & introduced English lock

and used in aftercoming head.

Tarnier (1877)-introduced axis traction.

Barton and Kjielland -introduced the two specialized forceps. Since then very few and minor developments have taken place.

Moreover since the advent of Vacuum extractor, many of the earlier highforceps applications have become obsolete.


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Classification of forceps

application

Classical (old) Classification : - Low/outlet forceps (no distinction): - forceps applied when

the foetal head/skull has reached the pelvic floor,

sagital suture has reached the A- P diameter of pelvisand scalp is visible without separating the vulva.

Mid forceps: - forceps applied when head is engaged

but criteria for low forceps not reached.

High forceps: - forceps applied when head is not

engaged.



Classification of forceps

application

Low forceps Foetal scalp is visible without separating the vulvaFoetal skull has reached the pelvic floor

Sagital suture is in the A.P.diameter or in the Lt./Rt. Occiputo

anterior/posterior position

Rotation does not exceed 45degrees

Outlet forceps The leading point of the skull is 2cm or more below the ischealspine but not on the pelvic floor

Sagital suture is in the A.P.diameter or in the Lt./Rt. Occiputo

anterior/posterior position

Mid forceps The leading point of the skull is 2cm or less above the spine buthead is engaged. Rotation not considered

High forceps EXCLUDED

Newer classification as per A.C.O.G.1981(revised in 1991):-



Types of Forceps

Classical instruments: -Originally designed by James YoungSimpson, Wrigley & George L.Elliot Jr in mid 19th centurycommonly used for outlet & low pelvic rotational delivery.

Modified classical instruments: -Overlapping solid bladeswith extended shanks like Tucker-Melane forceps, Elliot typecommonly used as mid pelvic rotators or outlet blades. May beoccasionally pseudofenestrated like Luikart's modification.

Specialized instruments : -Designed for specific indications like- Barton's for transverse arrest in platypeloid pelvis,

Keilland's for mid pelvic rotation & correction of asynclitism and

Piper's for delivery of Aftercoming head in breech.

Several hundred types of forceps have been designed which

can be classified into various types-.



Types of Forceps

Divergent or parallel blades instrument: -.

Designed to limit foetal cranial compression. Examples -

Laufe, Shute & Moolgaoker.

Axis traction instruments: -.

As a separate handle like bill's handle to be attached to

any standard forceps. Axis traction as an integral part of the forceps like Howk-

Dennon's& de Wee's forceps.

Several hundred types of forceps have been designed which

can be classified into various types-.



Functions

Traction: -This is the most important function. Pull required in a

primigravida is 18 kgs & in a multipara it is 13 kgs.

Compression effect: -This is minimal when properly applied & should

not be more than necessary to grasp the head. However it has some

pressure effect on the well-ossified base of the skull.

Rotation of head: -This occurs with the use of Kejilland's forceps and

also in low forceps cephalic application with the occiput in the 2 or 10 'o'

clock position.

Protective cage: - When applied on a premature baby it protects from

the pressure of the birth canal. When applied on the aftercoming head itlessens the sudden decompression effect.

As a vectis: - By applying one blade to deliver the head in caesarean

section.

I di ti f f



Indications for forceps

delivery

Delay in second stage: -. Due to uterine inertia.

Failure of progress of labour- if no progress occurs for more

than 20 to 30 minutes, with the head on the perineum.Definition of prolonged second stage of labour redefined byA.C.O.G.(1988/1991): -

Nullipara-




delivery

Foetal indications: - Foetal distress in second stage when prospect of vaginal delivery is

safe: -

Abnormal heart rate pattern

Passage of meconium

Abnormal scalp blood ph

Cord prolapse in second stage

Aftercoming head of breech

Low birth wt. Baby

Post maturity

I di ti f f




delivery

Maternal indication: - Maternal distress

Pre-eclampsia

Post caesarian pregnancy Heart diseases

Intra partum infection

Neurological disorders where voluntary efforts arecontraindicated or impossible



Prerequisites(to be fulfilled before forceps application.)

Suitable presentation & position: -. Vertex, anterior face or aftrcoming head are the ideal

positions.

Cervix must be fully dilated. Membranes must be ruptured.

Baby should be living.

Uterus should be contracting & relaxing.

Bladder must be empty.



Preliminaries(before forceps application )

Documentation: -

All instrumental deliveries should be dictated in medical record as any surgicalprocedure & it should include: Consent of the patient, indication for operation,anaesthesia, personnel involved, type of instrument, difficulties & remedies,resulting maternal & foetal complications or injuries and blood loss.

Anaesthesia:-

Pudendal block or Labio-perineal infiltration for outlet forceps. Regional or General anaesthesia for low & mid forceps.

Catheterisation:-

Internal examination: -

To asses the state of cervix & membranes, presentation & position, pelvic outlet,TDO & sub pubic angle.

Episiotomy: - Should be done either before application of forceps or during traction when the

perineum bulges.



Types of application(of forceps blades )

Cephalic application -. Blades are applied along the sides of the head, grasping the

biparietal diameter in between the widest part of the blades and the

long axis of the blades correspond to the occiputo-mental plane.

Pelvic application: -. Blades are applied on the lateral pelvic wall ignoring the position of

the head if the head is not rotated. Serious compression effect on the

cranium can occur, so it should be avoided.

When the head is sufficiently rotated, pelvic & cephalic applications

naturally coincide and so pelvic application is only justified in low

forceps operations.

T h i



Technique(of low & outlet forceps application )

1. Identification of blades & their application- The instrument should be placed in front of the pelvis

with the tip pointing upwards and pelvic curve forwards.

First the left blade should be applied guided by the right

hand & then the right blade with the left hand.

2. Locking of blades: -

The blades should articulate with ease indicting correct

application.

T h i




3. Clinical checks for correct forceps application: - Sagital suture lies in the midline of the shanks.

The operator is unable to place more than a fingertip

between the fenestration of the blade and the foetal head

on either side.

Posterior frontanalle is not more than one finger breadth

above the plane of the shanks of the forceps.

T h i




4. Traction: - Steady & intermittent traction to be applied during

contraction, first downwards (horizontal), backwards,

forwards & lastly upwards.

In outlet forceps - Only two fingers are to be introduced.

Traction is applied straight horizontal, upward & then

forwards.

Removal of blades - Right blade should be removedfirst.

T h i




5. In Occiputo-posterior position Blades are to be applied as usual but they should be

equidistant from sinciput & occiput

Traction - Horizontal till the root of the nose is under thepubic symphysis, then upward till the occiput emerges

over the perineum & finally downwards.

T h i


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6. In face presentation- Blades are to be introduced along the Occiputo-mental

diameter.

Traction is applied downwards till the chin appearsunder the symphysis pubis & then upwards delivering

the nose, eyes, brow & occiput.

T h i


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Technique(of mid forceps application )

Forceps used are - long curved with or without axis tractiondevice & Keillands.

Indication - following manual rotation in occiputo posteriorposition.

General anaesthesia is preferable. Blades are to be introduced only after manual correction of

malposition of occiput.

Traction - same as low forceps without axis traction. With axistraction, the traction rods should remain parallel with theshanks and should be removed when the base of the occiputcomes under the symphysis.


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Forceps for Aftercoming head

Piper's forceps are specially designed for this purpose. Forceps to be applied when the occiput lies against the

back of the symphysis

Blades to be applied from below after raising the legs.

Traction to be maintained in an arc, which follows the

axis of the birth canal.


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Keilland's forceps application

Indication: - Can be applied in unrotated vertex / face presentation and

for correction of asynclitism.

Application: -

Anterior blade is applied first followed by the posteriorblade.

In Wondering method in deep transverse arrest:- The

anterior blade is applied over the face and then moved overto the anterior parietal bone. The posterior blade is appliedbetween the head and the sacrum.

Blades also can be applied directly over the parietal bones.


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Keilland's forceps application

Complication: - Disengagement of the head may occur leading to cord prolapse.

Scanzoni-Smellie maneuver: -

Twice application. First the posterior blade is applied posteriorly

over the posterior ear and then the anterior blade is applied over the

anterior ear and head is rotated for 45o towards sacrum or 135 o

towards symphysis. Then blades are removed and reapplied.

Traction is applied as per Pajot's maneuver: -

Traction is applied horizontally with the right hand while pressing

downward with the left hand.

General anaesthesia is necessary.


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Complications / Dangers

Complications/dangers of forceps delivery: - are mostly due to faulty

technique rather than the instrument.

Maternal-

Injury-. Extension of the episiotomy involving anus & rectum or vaginal vault.

Vaginal lacerations and cervical tear if cervix was not fully dilated.

Post partum haemorrhage. Due to trauma, Atonic uterus or Anaesthetisia.

Shock. Due to blood loss, dehydration or prolonged labour.

Sepsis. Due to improper asepsis or devitalisation of local tissues.

Anaesthetic hazards.

Delayed or long-term sequel. Chronic low backache, genital prolapse & stress incontinence.


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Complications / Dangers

Complications/dangers of forceps delivery: - are mostly due tofaulty technique rather than the instrument.

Fetal-

Asphyxia.

Trauma- Intracranial haemorrhage.

Cephalic haematoma.

Facial / Brachial palsy.

Injury to the soft tissues of face & forehead.

Skull fracture

Remote-cerebral palsy.

Foetal death-around 2%.


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Prophylactic/Elective forceps

Introduced by Dee Lee (1920), refers to outlet forceps delivery,only to shorten the second stage of labour to preventanticipated maternal or foetal complications in -

Eclampsia

Heart disease

Previous c.s.

Post maturity

Low birth wt babies

During epidural anaesthesia

Trial

Failed


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Trialforceps

Knowing that a certaindegree of disproportion at

mid pelvis may make the

procedure incompatible,

low/mid forceps delivery isattempted, abandoning it at

the earliest in favour of

Caesarean section.

So it should be done only in

the O.T., keeping everything

ready for C.S.

When a vigorous butunsuccessful attempt ismade with the forceps,anticipating a successful

forceps delivery. Mostly it is due to lack of

obstetric skill and poorclinical judgment

Factors responsible are-Disproportion, Incompletecervical dilatation &malposition of foetal head

Failedforceps


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Conclusion

Considering all aspects, forceps delivery has still got aplace in modern obstetric practice and should be

considered in certain cases.

If performed judiciously by proper selection of casesand careful & timely application, forceps delivery can

be useful in reducing not only unnecessary caesarean

sections but also foetal & maternal complications dueto prolonged labour


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Forceps Delivery by Abhishek Jaguessar